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UNITED STATES OF AMERICA. 



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Yellow Fever, 



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THOS. O. SUMMERS, M.D., 

Professor of Anatomy and Histology in the University of Nashville, and 

Vanderbilt University \ 






COPYRIGHTED. 



v,. 1879. ^ 



NASHVILLE, TENN.: 

WHEELER BROTHERS, 

i8 79 . 










(. 



TO THE MEMOR Y OF 



THOMAS WILLIAMS MENEES, M.D., 

Associate Demonstrator of Anatomy in the Vanderbilt University, and University 

of Nashville ; 



MARTIN CLARK BLACKMAN, M.D., 

AND 

ORLANDO DUFF BARTHOLOMEW, M.D.. 

My former Students and Co-laborers, 
WHO FELL IN THE GREAT EPIDEMIC OF 187 8, 

THESE RECORDS ARE TENDERLY DEDICATED 



PREFACE. 



TT is with a considerable degrse of diffidence that I offer to the Pro- 
-■■ fession a work upon a subject of such momentous consequences 
as Yellow Fever. And yet, I cannot but feel it my duty to set forth, 
as best I can, the experience which I so richly enjoyed during the 
Epidemic of 1878. 

I have endeavored to do this plainly, concisely, honestly, and I 
trust, humbly, for the consideration of those of my brethren whose 
lines may fall in the places of the pestilence. 

T. O. SUMMERS. 

Nashville, January 1, iS?<?< 



CONTENTS 



Page 

CHAPTER I. 



ETIOLOGY, 



CHAPTER II. 
PATHOLOGY, . . ... . . . . 18 

CHAPTER III. 

CLINICAL HISTORY, ....... 41 

CHAPTER IV. 

TREATMENT AND PROPHYLAXIS, .... 57 



YELLOW FEVER. 



CHAPTER I. 
ETIOLOGY. 

THE disease which forms the subject of this treatise 
is the most formidable malady known to warm 
latitudes. It has received many names from the prom- 
inence given by authors and observers to the various 
phenomena of the disease. Cullen, I believe, it was, 
who denominated it Typhus Icterodes. It is the disease 
of Siam, the Mediterranean fever, the malignant bilious 
fever of America, the sailor's fever, and the Jievre jaune 
of the French writers. Its most familiar application, 
however, is Yellow Fever, from the yellow tinge which is 
assumed by the skin during the progress of the disease. 
Its natural home is in hot latitudes, along the coast of 
the Atlantic ocean, the Gulf of Mexico, and the great 
arteries of travel which flow into them. Along the Medi- 
terranean it has raged, and has occurred in the West 
Indies more in the endemic, however, than the epidemic 
form. Of later years, it has been extending the limits 
of its prevalence into the inlaVid towns of the Southern 
States lying in the track of travel and within the range 
of exposure to its infection. That it is confined to 
low, flat regions has been, by the late fearful epidemic, 
which has so devasted our Southern country, for- 



io YELL O W FEVER. 

ever set aside. That it depends for its existence upon 
the neglect of sanitary measures has been alike demon- 
strated to be utterly unfounded in fact, and the vaunting 
boasts of local boards of health who, because living in 
places not reached by the infection, lay the flattering 
unction to their souls that they have by any steps taken 
by them prevented its prevalence, must seem highly 
amusing to those who have seen its fearful ravages in 
places remarkable for their natural cleanliness and for 
their strict hygienic regulations. 

The town of Holly Springs, Miss., is a standing re- 
buke to all such vain assumptions. Nor are we to sup- 
pose that barometric or thermometric conditions of the 
atmosphere alone determine the possibility of its de- 
velopment. The barometer and the thermometer may, 
and often do, stand at the same point, at the same time, 
in an infected and a non-infected place ? We may go 
further than even this, and unhesitatingly declare that 
the quantity of moisture in the atmosphere at a given 
temperature cannot alone determine the propagation of 
Yellow Fever, or the elaboration of the morbific element 
upon which the disease depends. 

What, then, are the conditions of its development ? 
From patient and careful analysis of the atmospheric re- 
lations in those places where the disease has prevailed, 
as compared with those places of the same latitude 
where it has not, I am well assured, that by the use of 
the hygrometer we shall in time be able accurately 
to determine during any one season whether or not 
any given place enjoys an immunity from Yellow Fever. 

The condition of the air, as regards moisture, involves 
two distinct elements: (i.) The amount of vapor pres- 
ent in the air; and (2.) The ratio of this to the amount 
which would saturate the air at the actual temperature. 
Our sensations of dryness and moisture chiefly depend 



ETIOLOGY. ii 

upon the second of these elements, and it is this which 
we denote by the term humidity ; or, as it is sometimes 
called, relative humidity. The air is said to be dry when 
its humidity is below the average. This is usually ex- 
pressed as a percentage ; for example, if the weight of 
the vapor present is seven-tenths of that required for sat- 
uration, the humidity is said to be jo°. To illustrate this 
practically — the air in a room heated by a hot stove con- 
tains as much vapor, weight for weight, as the open air 
outside, but it is drier because its capacity for vapor is 
greater. In like manner the air is drier at noon than at 
midnight, though the amount of vapor present is about 
the same ; and it is for the most part drier in summer 
than in winter, though the amount of vapor present is 
much greater. Now the instrument furnishing a precise 
measurement of the state of the air as regards moisture, 
is called an hygrometer. The dew point, as it is called, 
is that point at which the density of the vapor in 
the air becomes equal to the maximum density corres- 
ponding to the temperature. It is in this state that 
moisture can be utilized in the elaboration of germ life, 
and the temperature at which the density is greatest 
without condensation of the vapor, constitutes the dew 
point, which it will thus be readily seen must vary at dif- 
ferent places. Now, even at the same temperature, and 
with the same amount of moisture in the air, there may 
be other conditions — such as electric currents, for exam- 
ple, which will cause a more rapid condensation of mois- 
ture at one place than another, and that place, according 
to my observations, during the summer of 1878, which, 
at the temperature necessary to elaborate a germ, showed 
the most rapid condensation of moisture, was, to that ex- 
tent, more favorable to the introduction and propagation 
of Yellow Fever. I feel positively assured that while 
these investigations upon my part, thus far, have been 



12 YELLOW FEVER. 

purely relative, the day is not far distant when we shall 
be able to determine the advance of Yellow Fever with 
the same accuracy that we now predict the movement of 
a storm wave. Furthermore, I have not the slightest 
doubt that the external conditions for the develop- 
ment of Yellow Fever may be found in the atmosphere 
alone ; nor do I believe that any amount of hygienic reg- 
ulations can do more than indirectly modify the propaga- 
tion of the disease by placing the subjects of infection 
upon a more healthful basis from which resistance to its 
influence may be more successfully offered. I should be 
far from discouraging sanitary measures, or throwing any 
obstacle in the way of the further development of that 
spirit of sanitary reform which has lately been inaugur- 
ated with such commendable enthusiasm ; yet I cannot 
but accept the fact, as it is forced upon us, that this ter- 
rible scourge is one of the powers of the air, and cannot 
be resisted except upon those general physiological 
principles which lie at the basis of all medical science. 

What I have said above applies only to the external 
conditions favorable to the reception of the disease in 
various localities. It now remains to set forth its own 
inherent conditions of development as relate to the or- 
ganism in which its phenomena are elaborated. 

Yellow Fever is a Zymotic, or fermentative disease, 
and as all fermentation is set up by small organisms, so 
do all the manifestations of the disease in the human sys- 
tem depend upon the deposit within the blood of living 
organisms, which in their growth and development pro- 
duce the morbid changes which characterize the course 
of the malady. I have never been able to establish the 
existence of a specific Yellow Fever germ. All that can 
be discovered to establish the specific germ nature of 
the disease is gathered from the presence of microzymes 
in the blood. These are not, however, of a specific 



ETIOLOGY. 13 

character. We encounter Bacteria, Vibriones, Torulae, 
Monads, but never a germ which specifically determines 
the characteristics of the fever. All of the phenomena, 
however, which are manifested in the disease may be 
accounted for, without recourse to the hypothesis of a 
specific germ. 

It is, I think, safe to assert that without a malarial 
basis of operation, Yellow Fever is never developed in 
any locality. It is a remarkable fact that at the begin- 
ning of every epidemic there are always conflicting 
opinions concerning the specific nature of the prevailing 
disease. It has been the history of every epidemic that 
malarial influences have been for some time prevalent, 
and that gradually by a process of enucleation, as it were, 
the disease assumes the epidemic form, after lopping off 
one symptom here and taking on another there, until the 
specific nature of the disease becomes permanently estab- 
lished. 

It is a well known fact that the atmosphere is at all 
times charged with germs, but they do not become infec- 
tious unless the relations of the heat and moisture in the 
air sustain a favorable relation to the sporulation, or fruc- 
tification of the germ. They are always thrown off from 
animal organisms in a matured condition, and unless 
they meet the necessary conditions for reproduction in 
the air, they die without throwing off a single spore. 
These conditions are found in a malarial atmosphere. 
For a long time the ordinary malarial fever prevails. 
This depends for its development upon heat and mois- 
ture alone — the action of the sun's rays upon moisture 
lying just beneath a thin stratum of earth, as has been 
suggested by Prof. W. K. Bowling, of Nashville, requir- 
ing no decomposition of vegetable matter whatever to 
develop it, since some of the worst malarial sections are 
those which have been remarkable for scanty vegetation. 



i 4 YELLOW FE VER. 

And now the atmosphere, just at this point of malarial 
development, sustains to germs deposited within it in a 
matured condition — a fructifying relation. 

Now, it is only when the germ begins to sporulate, or 
in other words, to give off an infant germ, that infection 
can result. It is only in the passage of the spore through 
its stages of development up to the matured germ that 
fermentation can result. Indeed, this it is which, by a 
peculiar catalytic action, as yet inexplicable upon any 
known principles of chemical philosophy, causes fermen- 
tation to take place in those fluids where the spore can 
receive its proper pabulum for development into the 
matured germ. This it assimilates at the expense of 
morbid changes wrought thereby in the blood in which 
it had been deposited. 

This opens up to us the question, Is Yellow Fever 
contagious ? Most assuredly not. The exuviae from the 
body of a patient are charged with matured germs which 
without a proper nidus for their sporulation would be 
perfectly harmless. Just as a grain of wheat might re- 
main upon a block of marble for many years without 
germinating, and when removed to proper conditions of 
soil, moisture, and heat, would begin at once to sprout, 
so does this matured germ when thrown off from the 
body float harmless in the air until the conditions are 
rendered favorable for its sporulation, the little spore or 
infant germ being the infecting agent. Thus it is readily 
seen- that infecting agents are developed outside of or- 
ganisms, which they ultimately infect. Not so with con- 
tagion, which is developed in and about the affected 
organization. It is not then, as has been carelessly 
asserted, a mere difference between tweedledum and 
tweedledee. There is a very wide and significant differ- 
ence between contagion and infection. Contagion de- 
pends not for its development upon atmospheric condi- 



ETIOLOGY. 15 

tions, but upon pathological conditions of the organism, 
while infection is developed without the organism by 
changes wrought in the germ under altered atmospheric 
conditions. In a non-infected atmosphere a healthy per- 
son may with impunity occupy the same bed with a 
yellow fever patient, whereas the exuviae from a small- 
pox patient will almost certainly develop the disease in 
any organism brought within the pale of contact. 

The question may now very reasonably be asked, 
Why is it that if these germs exist in the air at all times 
we do not oftener find them exerting this peculiar mor- 
bific effect upon the organism ? Why are epidemics not 
more frequent ? The answer is simple. It is not often 
that we find the relations of heat and moisture so well 
balanced in the atmosphere of any one season as to de- 
velop this powerful malarial influence on which the growth 
of the germs seems to depend, and the intensification of 
which determines the moulding of the general symptoms 
into a specific type. The same conditions which appear 
to be necessary to the development of this high grade of 
malarial fever, which generally is the avant courier of 
the Specific Yellow F'ever, are the conditions which seem 
to favor the sporulation of germs, and, consequently, 
their investment with the power of infection. And then, 
again, the conditions under which germs develop are dif- 
ferent, and it is a natural result that their expression at 
maturity should likewise be different. Indeed, in these 
lower forms of organized life there is scarcely anything 
more than a mere skeleton of function, which external 
conditions invest with expressions as variable as the con- 
ditions themselves. Hence we are not reduced to the 
necessity of seeking out for each specific disease a spe- 
cific germ, since the varying expressions of the organ- 
ism and the changing conditions which surround it, are 
sufficient to account for the difference in Zymotic ex- 



16 YELLOW FEVER. 

pression between the very same ferments, or catalytic 
agents. 

These facts, together with the failure to establish the 
source of transmission of infecting germs from place 
to place, now bring me to assert, what I believe, if 
properly interpreted, has been the experience of the 
past, and which I am satisfied will be the experience 
of the future, that * Yellow Fever is not necessarily an 
imported disease. If malaria is an indigenous disease, 
then is Yellow Fever' also, since it requires only this 
intensified malarial influence to furnish the groundwork 
of its development. The history of the last epidemic 
has shown that many small isolated places were infected 
where there was no possible chance for the importation 
of the disease, without knowledge on the part of the 
inhabitants, and in the larger towns and cities this 
aggravated form of malarial fever always ushered 
in the Specific Yellow Fever by gliding gradually into 
it by such perfect shading of symptoms as to render 
it almost impossible to determine where the Yellow 
Fever began, certainly not, where the malarial ended ; 
for this, indeed, was perpetuated by recurrent symptoms 
through the whole clinical history of the Specific Fever 
which followed in its wake. I know the strong indis-. 
position — to a certain extent as commendable as it is 
natural — to recognize the existence of any fact that 
would in any way reflect upon the interests of the coun- 
try in which it has fallen to our lot to live, and yet in this 
instance the fact demands our recognition. The issues 
have been so fearful that it is no longer expedient, nor 
possible indeed, to waive the investigation of their origin. 
We have already too long hugged the. delusive phantom 
of quarantine, which is as inhuman as it is unscientific 
and impracticable. The time has come when we must 
recognize without further equivocation the existence of a 



ETIOLOGY. 17 

monster in our midst, and bend all our energies to 
throttle and destroy him. There is no time to lose. 
Yellow Fever is the curse of our land — yes, of our land, 
and the sooner we come to a recognition of the fact the 
sooner shall we able to check the ravages of this most 
dreadful enemy to the social, political, and commercial 
interests of the South. As soon as the medical pro- 
fession gave up the fruitless discussion of the local 
origin of cholera and proceeded at once upon the sup- 
position of its indigenous nature to meet its attacks boldly 
and scientifically, just so soon did its power over com- 
munities begin to wane, until to-day in the cholera dis- 
tricts it has come to be considered as a dead letter in the 
roil of epidemics. 

So will it be with Yellow Fever just so soon as we 
wake up to the fact that it is liable at any time during 
the heated seasons to break out among us, whenever 
the atmospheric conditions are favorable. 

To what conclusions do we then come in regard to the 
origin and causes of Yellow Fever? 

I. It is a Zymotic, or fermentative disease. 

II. It does not depend upon a specific germ. 

III. It is ushered in by a train of intensified malarial 
influences which gradually glide into the specific fever. 

IV. It depends for its development upon atmospheric 
relations of heat and moisture. 

V. It is not a contagious, but an infectious disease. 

VI. It is a disease which may at any time spring up 
in Southern latitudes indigenously, whenever the atmos- 
pheric conditions are favorable. 



1 8 YELLOW FEVER. 



CHAPTER II. 
PATHOLOGY. 



I^HE Pathology of Yellow Fever, as set forth by dif- 
ferent authors, is strangely conflicting. The fact 
is, during an epidemic the demands are so great for 
medical services at the bedside, that it is seldom the case 
that dissections can be conducted systematically. I was 
fortunate enough, however, during the late epidemic of 
1878, to have extended to me the privilege of regular 
dissections at the dead-house of the City Hospital in 
Memphis, by that most estimable medical gentleman, 
Dr. Thornton, Marine Hospital Superintendent at that 
place. 

During the whole course of the epidemic we enjoyed 
the best facilities for dissections and pathological investi- 
gations. Proceeding upon what we believe to have been 
established as a fact beyond the shadow of a doubt, that 
Yellow Fever depends for its phenomena upon the de- 
velopment of microzymes in the blood, we might reason- 
ably expect to find here the beginning of pathological 
manifestations. During all stages of the disease we find 
the blood in an extraordinary state of fluidity. Even 
after death we find that the blood for several hours will 
flow freely from the severed vessels. To what may this 
condition be ascribed ? The answer to this question 
will open up many of the most important factors in this 
disease. The first action of the spore upon the blood 
is to set up in its glycogenic elements a rapid fermen- 
tation. As a result of this, we have a large amount of 



PATHOLOGY. 19 

carbonic acid set free. This agent, it is well known, is 
one of the strongest solvents of albumen held in molecular 
suspension in any fluid, which is its normal condition in 
the blood. No suspended substance is subject to os- 
mosis. It is for this reason that the albumen of the 
blood never passes out of the walls of the capillaries 
when it is in a normal state and relation to that fluid. 
But the very moment it passes from a state of molecular 
suspension to that of solution, it is at once subject to 
osmosis, and may pass through animal membranes, and 
be deposited in tissues to which blood vessels are distri- 
buted. Now, carbonic acid, one of the products of fer- 
mentation, is a solvent of albumen, and whenever it is 
set free in the blood it reduces the albumen from a state 
of molecular suspension to that of solution, thus render- 
ing it subject to osmosis, and opening up a series of 
pathological changes which determine, I may say with- 
out exaggeration, the most prominent features of the 
disease, as we shall see when we come to consider its 
clinical history. Of all the organs in the abdominal 
cavity 

THE SPLEEN 

seems to be most affected. So prominent is this patho- 
logical- feature, that it was difficult for me to convince 
many of my co-laborers that we had anything more than 
an ordinary malarial fever to deal with. 

There is great hypertrophy. In four instances I found 
the spleen eight inches long and five broad. The paren- 
chyma was greatly distended, the Malpighian bodies 
were swollen — -many of them ruptured. The coloring 
matter of the bile was diffused through the whole organ. 
Its histological characteristics were scarcely recognizable. 
The splenic vein was engorged with a pulpified mass 
which was evidently made up of the degenerated struc- 



20 YELL OW FE VER. 

ture of the organ. Albumen was largely deposited in 
the splenic substance in the form of stringy coagula. 
The hilum presented in almost every instance extensive 
structural lesions, which seem to have resulted from the 
interstitial deposit of albumen. The doughy consistency 
of the splenic substance resembles very much that con- 
dition of the organ known as amyloid degeneration. 
The difference in the character of the Yellow Fever 
spleen and that of the ordinary Intermittent Fever, leu- 
caemia and pseudoleucaemia, appears to be, that in 
Yellow Fever, as in all acute infective diseases, the 
spleen is soft and swollen, with a thin and tense capsule 
— sometimes even ruptured — while in the last named 
diseases, of which the Intermittent Fever is the most 
prominent, the organ is indurated forming what many of 
our Southern pathologists have denominated the ague- 
cake\ The color of the Yellow Fever spleen is of a 
yellowish tint, derived from the biliverdine, which is dif- 
fused through its substance. 

The pulp projects from the cut substance, rendering it 
uneven, and hiding the follicles and trabecular more or 
less from view. The septa are thickened, and appear as 
distinct gray lines running in every direction, and forming 
a complete network, within which the splenic cells were 
contained, colored with biliverdine. Some of my asso- 
ciates, among whom was the lamented Dr. Cheviss, of 
Savannah, suggested that these were hemorrhagic infarc- 
tions, and that the orange yellow pigmentation was due 
to hematoidine. This, however, was disproved by isolat- 
ing the cells by means of needles, and examining them 
under a % lens, when the distinct cellular character was 
brought out. 

It is a remarkable fact that LaRoche, whose investi- 
gations were mainly based upon the epidemic of 1853, 
in Philadelphia, lays so little stress upon the morbid 



PATHOLOGY. 21 

anatomy of the spleen in Yellow Fever. Indeed, 
after a few general remarks, he says simply, that "it is 
often found unchanged." This does not accord with my 
observations at all. In fact, I have never seen, except in 
one disease before — the Malarial Hematuria of the far 
South — such extensive structural derangement in the 
spleen. This suggests at once the well marked malarial 
features of the disease. 

THE LIVER 

is of a yellowish color, giving rise to the name by which 
it is well known to modern pathologists — the boxwood 
liver. It is almost entirely devoid of blood, but charged 
with biliverdine, which in certain lights gives the cut 
surface a slight greenish tinge. There is but little 
enlargement, if any, and, indeed, without any knowledge 
of the epidemic character of the disease, it might be 
often mistaken for the incipient stage of Yellow Atrophy 
of the Liver. There is no indication whatever of biliary 
secretion. I have often called attention to the fact that 
the liver of Yellow Fever patients and that of habitual 
drunkards w T ere remarkably similar in their structural 
appearances. I have failed to remark anything very 
extraordinary concerning the liver in Yellow Fever be- 
yond the simple cessation of function. This is the con- 
stant — the ever constant — pathological result of Yellow 
Fever. 

There seem to be no permanent marks of inflamma- 
tion, but a complete alteration in the condition of the 
liver. A section under the microscope shows indeed a 
congested appearance of the lobules and empty bile 
ducts, while the inter-lobular spaces around the inter- 
lobular plexuses are charged with the coloring matter of 
the bile. 

The Portal Vein appears greatly congested. It is gen- 



22 YELLO W FEVER. 

erally filled with a dark stringy mass, which, in the first 
ramifications of the vaginal branches, may be seen en- 
gorging the whole capacity of the vessels. There seems 
to be in almost all cases an absorption of fatty detritus, 
just as is seen in Yellow Atrophy of the Liver. It 
resembles that produced by phosphorus poisoning ; 
but instead of being diminished it is increased in size; 
and, indeed, in this condition it has been known to 
pathologists under the name of Yellow Hypertrophy. 
A varying number of punctate hemorrhages are seen, 
especially in the connective tissue. Under microscopic 
examination the yellow portions are seen to contain liver 
cells, which are filled with a large quantity of biliary 
coloring matter, either diffused, granular, or crystal- 
line. 

Taken as a whole, however, there seems to be pres- 
ent, even in the most aggravated cases of the disease, 
but little in the morbid anatomy of the liver to account 
for the formidable hepatic complications which attend 
the whole course of the disease. I am thoroughly satis- 
fied that these are of a negative character. The key 
seems to be turned tip on all secretion in Yellow Fever ! 
In the very onset of the disease there seems to steal 
over everything the paralysis of function, through the 
morbid changes in the nervous centers, presiding over 
the secretory apparatus of the organism. The only 
traces whatever of the biliary secretion we find in the 
biliverdine and cholesterine — the excrementitious consti- 
tuents of the fluid. These, like all other excretions, 
exist preformed in the blood, requiring no secretory 
apparatus to separate them, but simply passing by os- 
motic action through the walls of the blood vessels. So, 
also, with the perspiration, which is a pure excretion, re- 
quiring nothing but filtration to eliminate it from the 
blood. The urine would also flow freely, were it not for 



PATHOLOGY. 23 

the fact that there is, as we shall hereafter see, a me- 
chanical obstruction to its osmosis. 

THE KIDNEYS 

are hypertrophied, charged with biliverdine, and in some 
instances ruptured in the pyramidal structure. The 
pyramids of Ferrein are less subject to changes of color, 
but sometimes are increased in width, and become the 
seat of a grayish opacity or a yellow discoloration in the 
form of narrow and delicate lines. The yellowish-green 
discoloration is more marked in the medullary pyramids 
and their papillae. 

The bilirubine infarctions occur in Yellow Fever just 
as in the new-born ; and I have never seen in any other 
pathological condition the rhombic tablets of fine needles, 
often arranged in arborescent or stellate groups and 
clumps, which occur in the interior of the tubules, 
in the epithelial lining, in the inter-tubular tissue, and 
especially in the vessels. I have closely studied these 
formations, and find them to exhibit the reaction of 
biliary coloring matter on the addition of liquor potassae, 
washing away the excess of the fluid with water, and 
adding the proper strength of nitric acid, when there will 
result the successive rings of green, blue, violet, and red, 
extending from the periphery to the center. There 
seems to be no inflammatory condition of the kidney ; 
in fact, nothing to indicate its inability to perform its 
normal functions, but simply the mechanical stoppage 
through the albuminous and bilirubine infarctions. Upon 
no other ground can we explain the suppression which 
forms the most alarming symptom in this terrible 
disease. 

It is on this account that we fail to produce any action 
upon the kidneys by our ordinary diuretics. They are 
not at fault themselves — it is on account of these de- 



24 YELLOW FEVER. 

posits in the tubules and the pelvis that the urine cannot 
pass. It is not a physiological, but a physical obstruc- 
tion. The cause lies behind the filtering apparatus of 
the kidneys. It depends upon blood changes, which 
permit the deposit of material in the substance of the 
kidney, and preclude the possibility of the filtration of 
the urine, though it may be preformed already in the 
blood, and prepared for elimination from the organism. 
When we come to the treatment of this disease, we shall 
show what methods are necessary to correct this patho- 
logical condition. 

The Suprarenal Capsules do not seem to be much 
affected outside of the discoloration produced by bili- 
rubine and biliverdine exudation. 

THE STOMACH 

does not exhibit any traces of inflammation whatever 
after death. The mucous membrane is intact. I am at 
a loss to understand how so many pathologists make 
statements exactly opposite to this. In those cases 
which, from the onset of the disease, exhibit excessive 
tenderness about the stomach, I have found on post 
mortem examination not the slightest pathological change 
in the gastric walls. During the late epidemic, I have 
examined twenty-eight stomachs, selected from cases 
presenting the greatest divergence in their clinical his- 
tory, and I have seen nothing to indicate any anatomical 
lesion whatever. Nor have I met with any evidences 
of congestion, which have been remarked by those 
authors whose investigations show no inflammatory con- 
dition of the mucous membrane. It is, therefore, with 
hesitation that I make known the results of my own 
autopsies, since they are, upon this point, so totally at 
variance with those of other observers, for whose ac- 
curacy of investigation I have the most profound respect. 



PATHOLOGY. 25 

No less eminent an author and investigator than Da 
Costa, in giving the differentiae between Yellow Fever 
and Bilious Remittent, says of the former : 

"Autopsy shows inflammation or very great congestion 
of the stomach, and sometimes ulceration or softening." 

Of Bilious Remittent: 

"Autopsy shows congestion of stomach ; more rarely 
a high degree of inflammation." 

Dr. Hayne, of Charleston, as quoted by LaRoche, 
says, that in all the dissections, with scarcely one ex- 
ception, he found, on post mortem examination, changes 
in the gastric mucous membrane amply sufficient to ex- 
plain so well marked a symptom as the tenderness in 
question, as also the others mentioned, i. e. y the soften- 
ing with inflammation, and thickening and softening 
without inflammation, either with or without thickening. 

I repeat that I can not understand this ; for to none 
of us who conducted these observations did these changes 
appear. There surely must have been some pronounced 
difference in the type of fever upon which the investiga- 
tions were made. 

I am, however, compelled, even in the face of high 
authority, to state simply the facts as I observed them ; 
and we shall see as we progress that my observations 
are borne out by the clinical history of the disease, as 
seen in the epidemic of 1878, upon which this treatise is 
based. 

THE INTESTINES 

in some cases show a very considerable degree of inflam- 
matory action to have existed ; in others they exhibit no 
lesions of any sort. I have remarked in those patients 
whose attacks assumed a typhoid type a considerable 
ulceration of Peyer's patches. We found evidences of 
inflammation as far up as the opening of the ductus 
3 



26 YELLO W FEVER. 

communis choledochus into the duodenum. The villi 
appeared greatly congested. Brunner's glands were 
swollen by the injection of their excretory ducts with a 
greenish viscid fluid, which could be teased out of them 
under the microscope, but the nature of which I was not 
able to discover. The whole surface of the mucous 
membrane was bathed in biliverdine, which also floated 
all over the outer peritoneal covering, showing in the sun- 
light a beautiful opalescent play of colors. Along down 
the duodenum, and where there had been recent vomit- 
ing before death, extending up into the stomach, there 
was often to be found a greenish stringy substance, which 
could be traced through the bile duct to the gall bladder. 
This substance, when subjected to microscopical exam- 
ination, showed broken down blood corpuscles and de- 
generated liver substance, colored with a dark green 
pigment. The gall bladder was often distended with 
this, and, on being opened, it would quiver to the touch 
like jelly. It resembled in every respect, physically, 
meconium. Never have I found the gall bladder to con- 
tain bile. When the stomach was charged with the 
black vomit there was always a continuous chain of this 
substance from the interior of the stomach through its 
pyloric orifice to the duodenum, and thence through the 
bile duct to the gall bladder. The stringy flocculi of the 
black vomit resembled the solid portion of this substance 
in every respect, and I believe them to be identical. 

THE LUISTOS 

did not appear to be altered in structure. There is fre- 
quently an engorgement, with dark colored and altered 
blood at the posterior or lower portion. Sometimes there 
are black ecchymoses all over the surface of the lungs. 
The air passages are generally normal in appearance. 



PATHOLOGY. 27 



THE HEART. 



The substance of the heart is generally more or less 
softened and flabby. The interior is colored with that 
greenish tinge which pervades the tissues of the body 
generally. The character of the blood contained in the 
cavities of the heart is of a dark grumous character. 
The albuminous concretions referred to by LaRoche 
were not often found. Only in four cases were they ob- 
served. The aorta was deeply tinged at its origin with 
green, as also the orifices of the pulmonary veins. 

THE BRAIN 

presents several important pathological changes. The 
Cerebrum is less affected than any other portion. After 
removing the Centrum Ovale Minus, the Puncta Vas- 
culosa were found to be very much enlarged, and instead 
of the beautiful pink, there was this strangely pathogno- 
monic greenish tinge which is found throughout the 
organism. The sinuses of the dura mater are all more 
or less engorged and charged with a superabundance of 
Cholesterine, which, on account of the cessation of the 
functions of-J:he liver has remained in the general circul- 
ation. The Medulla Oblongata is softened in most 
cases, and the Pneumogastric Center is especially so. A 
section of this nerve just at its origin shows extensive 
cellular destruction, the result of acute and rapid inflam- 
mation. All the cerebral nerves appeared not only con- 
gested, but inflamed in most instances, and in many the 
inflammation had gone on to structural lesions. I am 
not, therefore, prepared to accept the conclusions of 
LaRoche, which, certainly, from what follows, must have 
been drawn from widely different pathological conditions 
which most assuredly did not manifest themselves in the 
epidemic of 1878. 



28 YELL OW FE VER. 

He says : 

11 Whether the changes found in the spinal organs are 
to be referred to inflammation 'may very properly be 
doubted. More properly are they to be referred to mere 
congestion, which has but too often been mistaken for 
the former, and to the hemorrhagic tendency which, as 
we have seen, constitutes a main characteristic of the 
disease. If, indeed, the medulla or its membranes have 
presented unequivocal marks of the inflammatory pro- 
cess, such cases may reasonably be viewed as exceptional 
— the effect of an accidental complication — and not as 
forming an essential part of the disease. Nor is it less 
true that the unaltered condition of the parts in most, or 
at least in very many cases ; the fact of their redness, 
in some instances, is no indication of the prior existence 
of acute morbid action, and is often found after other and 
very dissimilar diseases ; added to the circumstance that 
the serous effusion described as discovered in many in- 
stances cannot be viewed as a proof of prior disease, 
since it is found in subjects who have died from the most 
opposite causes, lead to the conclusion, that so far as our 
information extends, we are not to look to the spinal 
organs for the seat of any morbid changes of import- 
ance, or peculiar to or characteristic of Yellow Fever." 

Now, this I cannot accept. We shall see when we 
come to the clinical history of the disease that it strikes 
at the cerebro-spinal system of nerves, just as malarial 
fever attacks the sympathetic, the ganglia of which in 
Yellow Fever were diseased in exact proportion to the 
malarial complications in the particular case. This is 
well sustained by the clinical results. It is a well known 
fact that quinine acts as a physiological antidote to mala- 
ria by its impression upon the cerebro-spinal system, 
thus restoring the balance of antagonism between this 
system and the ganglionic, which has been disturbed by 



PATHOLOGY. 29 

malaria. And now, as the Cerebro-Spinal System is 
under the influence of another poison, the quinine cannot 
have in the disease the ordinary antiperiodic effect. 
Hence the total failure to receive any benefit from its 
administration in the late epidemic, since the field of its 
therapeutic operation was already occupied by the Yellow 
Fever poison. It only aggravated the inflammatory 
symptoms of the Cerebro-Spinal System, while it exerted 
no influence whatever upon the Sympathetic, which can 
only be reached through the medium of the other system 
of nerves ; and then the positive evidence of cerebral 
lesions which characterized this fever, the morbid indif- 
ference, the restless jactitation, ending often in delirium, 
left no room for doubt, even though the accuracy of our 
observations might be reasonably questioned. So . far 
am I therefore, from accepting the conclusion of La 
Roche, that I do not hesitate to assert my conviction 
that the Cerebro-Spinal System is the grand rallying 
point of all the pathological tendencies in this formidable 
disease, and I am satisfied that the experience of all my 
co-laborers will bear me out. 

We shall have occasion again to call up this point in 
discussing the treatment of the disease. 

THE SKIN. 

The discoloration of the skin which has given a name 
to the disease varies with the stage of the fever, and 
likewise with the intensity of the symptoms. The pallor 
which forms one of the prodromic symptoms is soon suc- 
ceeded by a rosy flush, which in its turn is followed by a 
yellowish tinge, deepening as the disease advances, 
remaining for a long time after recovery, and in case oi 
death becoming so pronounced as to suggest to the mind 
of the ordinary observer the name by which at present 
the fever is almost universally designated. This discol- 



30 YELL OW FE VER. 

oration, however, does not occur in all cases, and then, 
moreover, there are other diseases which are in no wise 
related to Yellow Fever in which the skin is just as much 
discolored. So that it is by no means pathognomonic of 
the fever. I have seen many cases in which there was 
not the slightest discoloration of the skin beyond the 
mere flush which is common to all fever. But while in 
Yellow Fever we do not always have this discoloration, 
there is a cutaneous change which takes place in most 
cases, which does not occur in any other disease, and 
that is the dusky violet-bluish color which the skin as- 
sumes. And even the succeeding yellow tinge which it 
takes on may be distinguished by the experienced eye 
from ordinary jaundice. It generally begins behind the 
ears along the course of the posterior auricular and 
occipital arteries. It then extends to the face and neck, 
and finally becomes generally diffused. After death the 
color deepens, and is rendered even more pronounced 
by the dark violet-colored splotches which are scattered 
over the whole body. In fact, there seems to be a deep 
modena base underlying the Chorium, which gives more 
of an orange tint to the yellow of this fever, thus distin- 
guishing it from that of ordinary jaundice. 

There seem to be no anatomical lesions in the struc- 
ture of the skin. Indeed, as I have before intimated, it 
is a remarkable fact that .there is but little, if any, struc- 
tural lesion in the organs of excretion during an attack 
of Yellow Fever. The great pathological characteristic 
seems to be the locking of the secretions and the arrest 
of absorption, while at the same time there is an exces- 
sive migration of white blood corpuscles which, by a 
species of autophagism take up all the nutritive elements 
which were intended for the use of the organism. From 
the beginning to the end there is a retrograde metamor- 
phosis of tissue. The tendency is ever downwards — the 
waste far outstripping the repair. 



PATHOLOGY. 31 

THE EXCRETA. 

As I have before remarked, there seems to be but 
little if any disturbance of the excretions during the 
course of Yellow Fever. They are frequently blocked 
up, but are always to be found preformed in the blood by 
the normal physiological process. 

THE URINE 

is generally pale and charged with albumen. After 
standing a few hours it emits a foul sickening odor and 
readily ferments. Sometimes it is highly colored with 
biliverdine, but it is usual for this substance to be exuded 
into the substance of the tissues before reaching the 
'urine. I append below the analysis of the urine in five 
typical cases of the disease. My facilities for making 
accurate quantitative analyses were not good, though suf- 
ficient for all practical purposes. 

CASE No. 1. 
William B , aetat. $1 — full habit; no abnormal di- 
athesis ; general health good ; ruddy complexion ; tem- 
perate habits ; type of the attack virulent from the be- 
ginning ; nervous symptoms predominating ; no black 
'vomit ; death on the sixth day after twenty-four hours 
suppression. Analysis made on the fourth day : 

Water, - 930.00 

Urea, - - - - - 32.00 

Creatine and Creatinine, - - 2.00 

Urates, - 3.00 

Mucus and Coloring Matter, - - 2.00 

Chlorides, ----- 6.00 

Sulphates, - - - - - 7.00 

Albumen, ----- 18.00 



1000.00 
Reaction Acid. Spec, grav., - 1030 



32 YELLO W FEVER. 

CASE No. 2. 

Annie W , aetat. 19 — light frame; nervous tem- 
perament ; fair complexion ; delicate health ; bad hy- 
gienic surroundings ; no black vomit ; temperature and 
pulse running high ; no suppression ; recovery slow. 
Analysis made on the eighth day : 



Water, 


935.00 


Mucus and Coloring Matter, 


4.00 


Creatine and Creatinine, 


2.00 


Urea, ----- 


28.00 


Urates, - 


5.00 


Chlorides, - 


6.00 


Sulphates, - 


5.00 


Albumen, - 


15.00 




1000.00 


taction Acid. Spec, grav., 


1026 



CASE No. 3. 

William C , aetat. 14 — spare build; uric acid di- 
athesis ; black vomit on the third day ; death with sup- 
pression on the fourth day. Analysis made on the sec- 
ond day : 



Water, -.--'- 


932.00 


Mucus and Coloring Matter, 


6.00 


Creatine and Creatinine, 


2.00 


Urea, ----- 


30.00 


Urates, - 


6.00 


Chlorides, : - - - 


4.00 


Sulphates, - 


3.00 


Phosphates, 


2.00 


Albumen, - 


15.00 




1000.00 


taction Acid. Spec, grav., 


1020 



PATHOLOGY. 



33 



This was the only case in which I detected the pres- 
ence of phosphates, except where Phosphate of Am- 
monia or some preparation of Phosphoric Acid had been 
freely used in the treatment. 



Nathan M- 



CASE No. 4. 
-, setat. about 40 — a strict vegetarian ; 



gastric symptoms very pronounced from the beginning ; 
black vomit ; nerve lesions well marked 



Water, 

Mucus and Coloring Matter, 

Creatine and Creatinine, 

Urea, 

Albumen, 

Urates, 

Chlorides, 

Sulphates, 

Reaction strongly acid. Sp. gr., 



death : 

938.00 
2.00 
1. 00 
35-oo 
20.00 
1. 00 
2.00 
1. 00 

1000.00 
1019 



CASE No. 5. 

Henry H , aetat. 26 — slender frame ; dissipated 

habits ; lithiasis ; suppression on third day, causing 
death. Analysis of last urine drawn : 

Water, 

Mucus and Coloring Matter, 

Albumen, 

Urea, 



Urates, . 

Chlorides, 

Sulphates, 



Reaction acid. Sp. gr., . 



928.00 
10.00 
18.00 
38.00 
6.00 
trace, 
trace. 

1000.00 
1030 



34 YELL OW FE VER. 

These were the only quantitative analyses made. I 
have not. recorded the fractions, as the balances were 
not delicate enough to arrive at anything more than an 
approximative result. This, however, is sufficient to 
establish a basis upon which to draw conclusions in 
regard to the urinary pathology of this disease, which 
in most cases, I may say, was the immediate occasion 
of dissolution. 



THE PERSPIRATORY GLANDS, 

being excretory organs, as we would naturally expect, 
are active. There is an excessive amount of excretion, 
especially in the first stages of the disease. The excre- 
tion itself is charged with biliverdine, and imparts a 
yellow color to cloth when dried upon it. It has a pecu- 
liar odor, which I do not venture much in affirming to be 
pathognomonic of the disease. In years past, I have 
often heard old nurses in the South declare that they 
could smell a case of Yellow Fever as soon as they 
stepped into the room where a patient was lying. Upon 
personal investigation, I am satisfied that they are cor- 
rect. I have tried to find some thing with which to 
compare it, but it is so positively sni generis that I have 
discovered as yet nothing which will im'part any definite 
idea of the odor to one who has not observed it, but the 
odor of mash in a brewery more nearly resembles it than 
anything else. The amount of perspiration fn this fever 
is remarkable. Oftentimes it is sufficient to saturate the 
covering. Most of the elimination of effete matters from 
the organism is carried on through the perspiratory sys- 
tem, and often it performs vicariously for several days 
the excretory functions of the kidneys. It seems as 
though nature in her efforts to sustain the organism against 
the destructive tendencies of this formidable disease relies 



PATHOLOGY. 35 

almost entirely upon the eliminative functions of the per- 
spiratory glands. 

Hence, as we might reasonably expect, the sweat of 
Yellow Fever contains much that does not really belong 
to this normal physiological excretion — much which, if 
not eliminated in some way, would by its toxic effects 
upon the organism render most certainly fatal the issue 
of the disease. 

THE BLACK VOMIT. 

Without any apparent structural lesion in the stomach, 
Yellow Fever has ever been known to be attended with 
a symptom which has stamped it with an individuality 
most certainly differentiating it from every other disease, 
and that is the ejection from the stomach of a peculiar 
matter ordinarily known as the Black Vomit. So 
exclusive an attendant upon Yellow Fever is this alarm- 
ing symptom, that the Spaniards have given to the 
disease the name Vomito Prieto, and Hippocrates has 
described this fever under the name of Black Disease, 
showing what importance he ascribed to this peculiar, 
and, as generally regarded, specific symptom. But 
recent investigations have show that it is not of itself 
pathognomonic of Yellow Fever ; for not only are there 
many cases in which it does not occur, but there are 
other diseases in which, under some circumstances, black 
matter is ejected from the stomach. 

There are certain poisons which, introduced into the 
organism, produce ejections like that of black vomit. 
It has also been observed in acute peritonitis, puerperal 
fever, and the vomiting of pregnancy. In the Malarial 
Hematuria of the South it has been frequently met with, 
and cases of bilious and remittent fever have been re- 
ported as having been attended with the same character 
of ejections as that of black vomit in Yellow Fever. 



36 YELL OW FE VER. 

This peculiar matter, however, belongs more to Yellow 
Fever than to any other disease ; and while it cannot be 
considered as a distinctively pathognomonic sign of this 
disease, it most certainly is one of the strongest diagnos- 
tic features in the whole course of the malady. 

In all of my autopsies, I found more or less of this 
substance in the stomach or intestines. Its color is not a 
decided black. Under a strong light it has been likened 
to coffee grounds. It is made up of stringy flocculi, 
which sink to the bottom of the vessel, and when gath- 
ered together, form a viscid gelatinous mass, which 
sticks readily to any surface. The quantity of the black 
vomit contained in the stomach varies much, I have in 
several instances found the stomach immediately upon 
death largely distended with it ; in others, I have found 
little more than a teaspoonful. It appears to be con- 
tinuous with the stringy contents of the gall bladder. 
Under the microscope it exhibits broken-down blood cor- 
puscles generally, but they are not always constant con- 
stituents of this substance. The dark substance which 
gives name to the ejection, is simply degenerated bili- 
verdine. 

I have already remarked that the liver does not secrete 
at all, it only allows the cholestrine and biliverdine — the 
excrementitious matters of the bile — to filter through 
into the hepatic ducts. Mixed with the broken-down 
lobular substance of the liver, we have a gelatinous, 
stringy mass, which resists all proximate analysis from 
the disintegrated and heterogeneous nature of the mate- 
rial entering into its formation. Under the microscope it 
presents the appearance of defibrinated blood after the 
corpuscles have been macerated. It was formerly sup- 
posed that this peculiar substance exuded through the 
walls of the stomach, which by continued congestion of 
it s ucous membrane could no longer retain its accum- 



PATHOLOGY. 37 

mulated and disorganized blood. But there are two 
facts which forbid such a conclusion. In the first place, 
we have seen that the stomach is not in a congested 
condition after death. I have had the opportunity in 
several instances of opening the cavity of the abdomen 
in five minutes after death, in persons dying from suppres- 
sion, and nerve lesions just immediately before the black 
vomit should have been ejected. I have found the 
stomach distended with it, and yet not the slightest 
structural lesion in its walls, or, indeed, evidence of 
inflammation or congestion. 

And then, secondly, the black vomit itself only con- 
tains disorganized blood as an accidental constituent. 
The fact that it gives the reaction for the excrementitious 
matters of the bile, and that it contains unmistakable 
evidences of broken-down lobular substances from the 
liver — point conclusively to the hepatic origin of the black 
vomit. The pyloric orifice of the stomach is really 
closed after the sympathetic system has been thoroughly 
under the toxic effects of the disease, so that there is 
no obstruction to the passage of the contents of the gall 
bladder, or of the hepatic ducts opening by the common 
bile duct, into the duodenum. Moreover, a section of 
the liver through the division of the portal vein, shows 
the accumulation of a large quantity of this same matter 
— the manifest result of structural disintegration, which 
is almost as readily taken up by the bile ducts as the 
bile itself. And then, too, this very disintegration of the 
liver substance extends to the hepatic ducts, and passes 
readily through them. 

The theories in regard to the origin and nature of the 
black vomit are so numerous, that in a work like this, 
the scope is too limited to admit of even the statement 
of them. I therefore, confine myself to my own obser- 
vations and conclusions. I feel well assured that there 



38 YELL OW FE VER. 

is still very much to be discovered in this direction. 
And yet that the excrementitious matters of the bile 
form the main constituency of this ejection I do not 
think admits of doubt, for the reasons which I shall 
tersely recapitulate, as follows : 

i. It cannot be the product of a morbid secretion of 
the inflamed vessels of the stomach, since the black 
vomit is seen to exist in great quantities where there is 
no evidence of gastric inflammation, or even congestion. 

2. It cannot be vitiated bile, since it occurs when the 
liver is most inactive, when there is no secretion of bile 
whatever. 

3. It cannot be altered blood, since the presence of 
blood, however altered, is always indicated by a reddish 
tint, which is not always observed in black vomit, and 
when found, is due to the haematemesis occurring very 
frequently in the last stages of Yellow Fever. 

4. It must be of a biliary character, however, since it 
gives the reaction for the coloring matter of bile.' 

5. It is not a homogeneous fluid, and, therefore, can- 
not be a secretion. 

6. The constant presence of degenerated lobular sub- 
stance shows that its origin is outside of the stomach, in 
which organ no pathological change can be found to 
account for the existence within it of the ejection. 

7. It can, therefore, be nothing more nor less than the 
excrementitious matters of bile, which exude when the 
liver is not secreting at all, mixed with broken-down liver 
substance, mucus, highly acid gastric juice, and altered 
blood, whenever the disease takes on the haemorrhagic 
tendency. 

The other points connected with the time and the 
mode of ejection will be discussed under the clinical 
history of the disease. 



PATHOLOGY. 39 

THE FAECES. 

The tendency of Yellow Fever is to constipation, and 
the discharges when brought about by aperients or 
cathartics, are peculiarly offensive. They are very acrid 
in character, and after the third day generally contain 
much of the same matter that is ejected from the 
stomach as black vomit. They readily ferment on stand- 
ing, and emit a sour smell. Under the microscope they 
are seen to be fairly swarming with torulae and bacteria. 
Hemorrhages are frequent, and in the epidemic of 1878, 
much more so than in any previous. The mucous mem- 
brane of the intestines is exfoliated, and passes off with 
the discharges, to a greater or less extent dependent 
upon the inflammatory nature of the disease. In all 
cases there are found large quantities of epithelial scales, 
which pass off often in complete rings. 

THE BLADDER 

is generally found shrivelled, and with thickened coats. 
There is very little, if any, indication of structural lesion 
in the mucous membrane, which is generally healthy. 
It is lined with mucus, colored heavily with biliverdine. 
During the late epidemic the bladder was generally 
found empty. Frequently, we found pure blood, and 
sometimes a fluid resembling black vomit, which, when 
mixed with urine, showed a discharge similiar in physical 
appearance and chemical reaction to that which charac- 
terize Hemorrhagic Malarial Fever. 

THE PHYSICAL CONDITIONS 

of the organism during an attack of Yellow Fever are 
very much altered. 



40 YELL 0W FE VER. 

THE HEAT 

of the body is intense, the temperature running as high 
as 106 F., and in some instances as high as no.° I 
can see no better way to account for this degree of heat 
than to regard it as due to the excessive amount of fer- 
mentation developed in the blood. The internal heat of 
the organism is very great. On opening a subject 
immediately after death the internal organs feel as 
though they had been dipped in boiling water, and the 
diffused fluids of the body by which they are surrounded 
are hot and steaming. Indeed, it seems as though it 
were impossible for any organ to perform its function in 
such a pyretic condition of the tissues. The system is 
literally burned out. 

THE OSMOTIC CONDITION 

of the organism is above the normal standard. Exuda- 
tion is free, and the diffusion of fluids extensive. While 
this is true, as we have before remarked, there is little 
or no secretion going on in the glandular system. The 
blood gives up all excrementitious matter readily, but the 
glands do not take up the elements out of which to form 
their peculiar secretions, or if they do take them up, do 
not form the secretions, but remain engorged with the 
mass which it cannot work up to a physiological relation. 






CLINICAL HISTORY. 41 



CHAPTER III. 
CLINICAL HISTORY. 

IN the description which I shall give in this Chapter 
of the Yellow Fever, at the bedside, I shall follow 
the order in which the symptoms arise, so as to give as 
vivid a picture of the disease as possible to one who has 
never observed a case. 

I have found it utterly impossible accurately to divide 
the disease up into stages. The symptoms so often 
crowd in upon each other, overlap and interlace, that I 
do not believe it possible to make a classification of 
symptoms upon any such division into stages, as that 
adopted by Copeland, LaRoche, and others. I shall, 
therefore, confine myself strictly to the pathological 
order of the symptoms as manifested in the disease at 
the bedside. 

The onset of the disease varies in different persons. 
In most instances it is ushered in by a chill. This, how- 
ever, is not well marked, generally consisting of rigors 
down the back, and chilly sensations passing now and 
then by a wave-like movement through the system. It 
is not an ordinary malarial chill, since it never returns. 
It is in many instances a simple feeling of malaise, 
attended with stretchy sensations, which run through the 
body at intervals. Indeed, the condition, more than 
anything else, resembles that indicated by the prodromic 
symptoms of an ordinary chill. There is considerable 
anorexia, amounting sometimes to a loathing of food. 
There is generally headache, languor and lassitude — in 
4 



42 YELL O W FE VER. . 

all better expressed by the one French word — malaise. 
It is usual for the patient to attribute these symptoms to 
general causes — such as overwork, exposure, or even 
ordinary malarial influences. They are rarely willing to 
admit that they are the subjects of the prevailing disease. 
The same delusive hopes that are so peculiarly charac- 
teristic of consumptive patients are indulged in, to even 
a greater extent, by the subjects of Yellow Fever. It is 
difficult to prevail upon them to go to bed, so positively 
do they generally resist the onset of this disease. After 
this sense of languor and lassitude there follows imme- 
diately — sometimes occurring simultaneously — pains in 
the back of the neck, in the whole spinal column, in the 
lumbar regions, and in the limbs, which increase towards 
evening, becoming very intense at night. The eyes are 
dull and injected, filled with water, and wandering rest- 
lessly from point to point. There is considerable moodi- 
ness and depression of spirits, and the patient soon 
becomes irritable and restless. This continues twelve 
hours or more. The febrile stage now comes on. The 
eye becomes restless, the countenance anxious, the 
tongue thickly coated, and the pulse bounding, compres- 
sible, gaseous, and frequent. The temperature of the 
body runs up rapidly. In most cases it reaches 104 
Fahr., in many 106 , and in some even as high as no°. 
And now what is so very remarkable about this strange 
disease, the rise in the temperature is accompanied by 
the most profuse perspiration, of a very offensive odor, 
and staining the bedclothes when dried upon them. 
Here is the point d ' appni — the first point of variation 
from ordinary malarial fever. In the last named fever 
there is first the cold stage, then the febrile stage, when 
the skin is dry, hot, and shrivelled ; and after this the 
decided sweating stage, which ends the periodic pheno- 
mena developed by the poison. There is no blending, 



CLINICAL HISTORY. 43 

but a well marked pathological pause, if I may so speak, 
between the different stages of a periodical expression 
of Malarial Fever. Not so with Yellow Fever, where 
the perspiration is often most profuse when the temper- 
ature of the body is highest, and with both of these the 
pains are often most intense. 

The pulse runs very high. In the first twenty-four 
hours generally keeping along pari passu with the tem- 
perature. 0( four hundred and eighty-two cases the 
highest record I find to be 128 in an adult, and 132 in 
a child of 4 years of age. In the accurate and beauti- 
fully arranged report of Dr. E. O. Brown, Physician in 
charge of the Yellow Fever Hospital in Louisville, I find 
the highest range of the pulse to be 140 , in a female 
patient 19 years of age. This is the highest range I 
have ever seen authentically reported, and higher than 
I have ever observed myself. Under the finger it is 
very compressible and rolling, just as though air bubbles 
were chasing each other along the arterial current, giving 
rise to the term gaseous pulse, the appropriateness of 
which can only be appreciated by those who have felt 
the peculiar sensation imparted to the finger. Nor is 
this a mere tei'm of resemblance ; for the fermentation in 
the blood is now at its height, and the carbonic acid is 
set free to such an extent as in reality to fill the current 
with bubbles. The arterial walls are soft and flabby, 
with but little muscular tonicity, strongly paradoxical 
as this may seem. There is just sufficient muscular 
action in the arterial walls to keep up the rhyth- 
mical action with the rapid beat of the heart, and 
to carry on the impulse given to the seething blood at 
the fountain of the circulation, and the slightest pressure 
will check the current at once. Under the paralysing 
influence of the malarial poison with which the Specific 
Yellow Fever is complicated, the sympathetic system of 



44 YELL OW FE VER, 

nerves have no antagonizing effect upon the circulatory 
apparatus, and the excitement of the Cerebro-Spinal 
System increases doubly the vascular congestion, just as 
though the sympathetic had been cut and the Cerebro- 
spinal unduly stimulated. This phenomenon throws 
much light upon the pathology and treatment of the dis- 
ease, as we shall see further on. 

The anorexia which marks the onset of the disease 
in most cases continues until the third day, the patient 
rarely suggesting a desire to eat anything. The thirst 
is, however, intense, and not easily gratified. The res- 
piration is quickened and not as deep as the normal. 

The bowels are constipated with rare exceptions. 
The feces are colored with bile, and are seldom altered 
in their appearance. They yield, however, a very offen- 
sive odor, and when allowed to stand in tepid water will 
soon began to ferment. A solution of them shows num- 
erous microzymes, of the same character as observed in 
the blood and urine. 

The urine is scanty, and in many instances suppres- 
sion takes place in the very outset of the disease. There 
are cases which die very soon, and show at post mortem 
examination extensive albuminous infarction of the kid- 
ney. As before remarked, the suppression is mechani- 
cal and due to the obstruction of the tubes of the kidney. 
Uremia rapidly sets in when the suppression is first 
marked. The patient now begins to feel a sense of 
perfect nervous repose, provided there have been no 
lesions at the base of the brain preceding the suppres- 
sion. The time at which suppression is generally mani- 
fested is the third day, though in some instances album- 
inous urine is passed at the very beginning of the 
attack, followed immediately by infarction, and, conse- 
quently suppression. In Memphis, this pathological 
condition was by far the most prominent feature in the 



CLINICAL HISIORY. 45 

disease — so much so, that patients would frequently 
demand the repeated introduction of the catheter to 
determine whether or not suppression had set in, and 
we could never fail to discover the mental depression 
which followed upon any failure to draw urine. 

On the third day, in most cases, there seems to be a 
point at which the disease decides which pathological 
direction it will take — whether to play upon the organs 
of urination, those of digestion, or the great nervous 
centers at the base of the brain. 

Frequently, after the stage of pyrexia, if I may so 
call it, which lasts for nearly three days, the pulse drops 
while the temperature remains the same. This is always 
an alarming symptom, though the alluring sensations 
which this pathological relation induces in 'the patient 
are likely to lead the inexperienced observer to hope that 
the case will terminate rapidly and favorably. But not 
so ; it is much easier to bring down a pulse than to bring 
it up ; to diminish vitality than to build it up ; and when 
once the system takes on the retrograde metamorphosis 
of this terrible disease, the descent is rapid, and the issue 
almost inevitably fatal. Yet it is here that the delusive 
hope is strongest in the patient's mind, and I have re- 
marked that the more positive the evidences of dissolu- 
tion the more hopeful does the patient feel. Nor is this 
the case only with those whp are not acquainted with this 
peculiar fact in the Clinical History of Yellow Fever. 
Often have I discussed it with my co-laborers during the 
late epidemic, many of whom when stricken,' would 
most strenuously insist that they were recovering when 
the death - damp had already gathered upon their 
brows. 

So long as the pulse and the temperature run pari 
passu, the issue is likely to be a favorable one, and just 
in proportion to the discrepancy between the pulse and 



46 YELL OW FE VER. 

thermal range are the chances for recovery doubtful. 
This is often very rapid. I have known the pulse to 
jump from 128 to 6o° in six hours. Such a case is nec- 
essarily fatal. Generally, however, on leaving a patient 
at night with a pulse and temperature running even, I 
have found on the next morning the temperature but 
little altered, and the pulse steadily descending. In 
these cases, while the prognosis is unfavorable, an op- 
portunity is afforded by judicious stimulation to bring up 
the pulse, while the heat of the body is reduced by means 
I shall hereafter describe. 

The discoloration of the skin begins generally on the 
third day; frequently later; and in some instances does 
not take place until dissolution has set in. At first, the 
face and neck are very red, and the change to the pecu- 
liar yellow begins just behind the . ears. Being due to 
the exudation of biliary coloring matter, it occurs after 
the capillaries have become congested, thus producing 
the red color which marks this stage of the fever. The 
time at which the yellowish tinge is assumed is a very 
good indication of the progress of tissue metamorphosis. 
If it is late in coming on, it indicates a high degree of 
inflammatory action, which drives the blood through the 
capillaries and prevents the exudation of biliverdine from 
their walls, and consequent infiltration into the surround- 
ing tissues. My experience is, that the prognosis is 
decidedly more favorable when the red of congestion 
yields early to the yellow of exudation. 

When the digestive organs are the chosen seat of 
pathological action in Yellow Fever, the symptoms are 
very distressing. This arises from the fact that they are 
not as they might seem, directly affected, but depend for 
their pathological expsession upon the irritation of the 
Pneumogastric nerve — the sympathetic plexuses in the 
abdomen keeping up violent reverse peristaltic action, 



CLINICAL HISTORY. 47 

and allowing nothing to be introduced either by way of 
alimentation or Medication. 

The black vomit generally occurs toward the close of 
the fourth day; frequently earlier. It is preceded by 
retching, hiccough, twitching of the muscles of the lips, 
and a decidedly Hippocratic face. These premonitions, 
however, are not always so pronounced, and the attend- 
ants frequently receive the whole contents of the stomach 
at one gush in their faces and upon their clothes. I 
remember upon one occasion being saved from a baptism 
of black vomit by my venerable friend and co-laborer, 
Prof. Dowell, of Galveston, who, as I was leaning in- 
tently over a patient, seized me suddenly by the arm and 
drew me back from the bed just a moment before the 
ejection w T as made almost to the top of the musquito 
bar. In this instance, there was only a slight retching, 
and nothing further to indicate such a sudden, powerful, 
and tremendous contraction of the gastric walls. Often 
there appears to be no effort at ejection whatever. There 
is generally but little nausea, and the whole process 
appears to be more of a mechanical than a physiological 
nature. 

The amount of the ejection varies greatly. In some 
instances it amounts to only a few stringy flocculi float- 
ing in the liquids which have been introduced into the 
stomach, or in the fermenting gastric juice which oozes 
or runs from the mouth. Often, however, the stomach is 
filled with it. I have seen as much as a quart ejected in 
the space of an hour, and I have already in the Chapter 
upon Pathology spoken of a case dying just before the 
ejection would have been made, which showed the 
stomach, on autopsy, to be greatly distended with black 
vomit. 

Immediately after the ejection the patient is livid about 
the lips — there is a sardonic contraction of the upper 



48 YELL O W FE VER. 

lip — a glaring look from the eyes ; in a word, the most 
intense expression of co-mingled disgust and despair. 
He generally appreciates the gravity of the symptoms, 
and sullenly yields to his fate, which is popularly believed 
to be inevitable death. This, however, is not true. 
During our late epidemic I made the following observa- 
tions : 

Out of four hundred and eighty-two cases seen, I 
have in my note-book recorded two hundred and thirty- 
seven deaths preceded by black vomit. This includes 
all cases in which there was even the smallest quantity 
of the ejection. Of the cases which recovered I have 
noted thirty-nine who had black vomit, some of them 
marked "copious" Of these, twenty-eight were chil- 
dren, whose ignorance of the gravity of the symptom 
protected them from its depressing effect upon the mind. 
This shows that black vomit is by no means a* neces- 
sarily fatal symptom, and that the popular idea that it is, 
tends greatly to depress the mind of the patient, and 
diminish the chances of recovery. 

The ejection of the black vomit is generally attended 
by intense thirst, and acidulated drinks are preferred. 
After all vomiting has ceased, the patient frequently 
craves outre articles of food — such as even a healthy 
stomach can with difficulty digest. Often he will resort 
to strategem to procure the things that he craves, and 
will carefully conceal the fact from the physician and 
attendants. If the case is going to result fatally this 
craving will soon be followed by the anorexia which 
characterized the onset of the disease ; if favorable, it 
will increase from day to day, until it becomes almost 
intolerable. 

The time which elapses between the ejection of the 
black vomit and death, if it occurs, is generally short, 
for, from the pathology of this symptom, we have seen 



CLINICAL HISTORY. 49 

that it is the evidence of disorganization and arrest of 
all nutritive functions. Many patients fall back and die 
immediately after the ejection ; while others begin at 
once to sink, and pass off in a few hours. 

THE TONGUE. 

At the beginning of the disease, the tongue is quite 
ngoist, very red at the tip and on the sides, and covered 
with a yellowish-white fur. It quivers very much like 
the typhoid tongue. From day to day the character of 
the tongue is changed. Frequently in twenty-four hours 
after the beginning of the attack, it is perfectly clean 
and of an intense crimson hue. Its circumvallate pa- 
pillae are thrown up in bold relief. In fact, I have never 
seen in any other fever this peculiar appearance brought 
out as it is in Yellow Fever. The circumierence appears 
to be everted and the center projected upwards. Where 
the disease is of an intense grade the tongue soon be- 
comes pointed and elongated, and resembles the tongue 
of typhoid fever in almost every respect. The fur 
appears at first white, and then turns yellowish. It is 
easily detached from the tongue, but readily returns. 
Throughout the whole course of the fever the patient 
complains of a bad taste in his mouth, and nothing ap- 
pears to remove it. 

THE ODOR 

of the skin in Yellow Fever has already been referred to. 
It is frequently observable, even before the attack has 
been fully established. Generally, it is manifest in about 
six hours after the chill or rigor which ushers in the 
fever. It permeates the bedclothing and fills the whole 
room. The patient himself perceives it. On the third 
day it is most marked, and continues even through con- 
valescence. This odor occurs in no other disease, and I 



50 YELLO W FEVER. 

regard it as distinctively pathognomonic of Yellow- 
Fever, though most authors simply notice the fact of its 
existence, without laying any stress upon its diagnostic 
value, 

I now propose to arrange in order for ready reference 
the symptomatology of the disease, with direct regard to 
its differential dianosis. 

There is but one disease with which it is possible to 
confound the Specific Yellow Fever, and that is the 
so-called Pernicious Malarial Fever. That this should 
be so is natural, since the two diseases, especially in the 
late epidemic, are so intimately blended in the system. 
And yet, through all the shading of the symptoms, there 
is a distinct line of demarcation between the two, which, 
however delicately drawn, close observation will always 
disclose. 

DIAGNOSIS. 

Yellow Fever in its original purity is not likely to be 
confounded with any other disease ; but of late years, 
in the process of assimilation, if I may so call it, which 
goes on in the history of every disease that is originally 
imported, the symptomatology has been materially modi- 
fied. The same law which governs vegetable and 
animal life is applicable also to disease. From year to 
year diseases which were imported in their purity take 
on the livery of the country to which they have been 
carried, until they become to all intents and purposes 
indigenous. Now, this is very remarkably manifested in 
Yellow Fever. Formerly, there was no difficulty in 
diagnosing a case, but of late it has been so continuously 
under the modifying influence of our Malarial Fever of 
the Mississippi Valley, that, like the original typhoid, it 
has become difficult, in many instances, to discriminate 
between them, especially before the epidemic character 



CLINICAL HISTORY. 



5* 



of the disease has been established. I shall give, how- 
ever, below a comparative table, by which the various 
shadings of the two fevers as they are expressed, even 
at once in the organism, may be determined. 



YELLOW FEVER. 

PERIOD OF INCUBATION 

Generally from five to nine days ; some 
cases reported as long as twenty- 
seven days, but not well authenti- 
cated. Epidemic of 1878 showed 
the average to be five days. 



MALARIAL FEVER. 

PERIOD OF INCUBATION 

Not definite — the poison being gen- 
erally diffused, and only awaiting 
certain conditions of the organism to 
express itself. It may lie in the sys- 
tem for months, when a change of 
condition and circumstances will DE- 
VELOP it. 



USHERED IN 

by a chill — often not well defined — 
sometimes only a slight rigor; with 
intense pains or uneasiness in the 
head, back, and loins, frequently ex- 
tending to the limbs. The paroxysm 
does not return. 



USHERED IN 

by a decided chill and general ma- 
laise, which returns periodically, and 
continues until antidoted by reme- 
dies. Headache or fulness in the 
head ; seldom pain in the legs or 
loins. Uneasiness generally confined 
to the vertebral column. 



THE STOMACH. 



Generally irritable. Nausea fre- 
quently severe ; vomiting distressing ; 
Epigastric tenderness marked from 
the beginning. 



THE STOMACH. 

In the beginning not so marked. 
Epigastric tenderness not so decided. 
Nausea and vomiting not so severe. 
Vomiting of bile and the contents of 
the stomach. 



THE EXPRESSION. 



The eye watery, highly injected, 
and restless. Countenance anxious. 



THE EXPRESSION. 



The eye dull, but not remarkably 
changed. Countenance languid. 



TONGUE. 

In the pure Yellow Fever the 
tongue is clean, or but slightly coat- 
ed; but in proportion as the disease 
assumes the malarial livery does the 
tongue become heavily coated and 
furred. Towards the last becoming 
pointed and very red. 



TONGUE. 



Heavily coated throughout. Be- 
comes thickened instead of pointed. 



52 



YELLOW FEVER. 



YELLOW FEVER. 

PULSE. 

Variable. At first runs very high, 
becoming slower toward the last. 
But slight, if any, remission. When 
noticed, generally occurring in the 
morning. 

TEMPERATURE. 

Very high from the beginning. 
Remission seldom marked — like the 
pulse — generally occurring in the 
morning. Continues high while the 
perspiration is pouring from the 
body. 

THE MIND 

generally clear. Delirium does noit 
occur until towards the close of the 
the disease. Patient hopeful. 

URINE. 
Scanty; albuminous; frequent sup- 
pression from infarction of the kid- 
ney tubes. 

PROSTRATION 

rare ; the muscular system least af- 
fected. 

HEMORRHAGES 

frequent ; from gums, nose, pharynx, 
and stomach. 



MALARIAL FEVER. 

PULSE. 

Not so variable. Quick until con- 
valescence sets in, but remitting with 
the intervals of the paroxysms. 



TEMPERATURE. 

Purely paroxysmal; falls when the 
sweating stage begins, to return with 
the next paroxysm. Not generally so 
high as in Yellow Fever. 



THE MIND 

always dull. Delirium frequent, even 
in the first paroxysm. Patient irrit- 
able and despondent. 

URINE. 

No albumen ; highly coloi^ed but 
not scanty ; suppression rare. 



PROSTRATION 

great; general indisposition to exer- 
tion. 

HEMORRHAGES. 

No tendency to hemorrhage. 



DURATION. 



short ; generally from three to seven 
days. Convalescence generally rapid. 



DURATION 



long ; unless antidoted, lasting for 
months. Convalescence tedious. 



PROGNOSIS. 

Decidedly unfavorable. Death 
rate very high, and treatment unsat- 
isfactory. 

SEQUELAE. 

Generally followed by no unpleas- 
ant effects upon the organism ; in 
some instances, however, affecting 
the nervous system for many months. 



PROGNOSIS. 

Slight mortality ; very amenable to 
treatment. 



SEQUELS. 

Very tedious ; general debility, 
anorexia, and restlessness. 



CLINICAL HISTORY. 53 



YELLOW FEVER. MALARIAL FEVER. 

SUBSEQUENT IMMUNITY. SUBSEQUENT IMMUNITY. 



One attack generally predisposes 
to another. 



Not decided. One attack renders 
a second attack less liable. Of late 
years the malarial livery has dimin- 
ished the degree of immunity which 
formerly characterized the disease. 

PHYSICAL CHARACTER. PHYSICAL CHARACTER. 

Epidemic; disappears with frost; Endemic; may occur all through 



formerly an exotic ; rapidly becoming 
indigenous. 



the winter; originally indigenous. 



THE TERMINATION 

of the fever in either death or convalescence is, as we 
have stated, rapid. Upon the fourth day the patho- 
logical direction of the disease may generally be deter- 
mined. If death is going to ensue the mind becomes 
wandering, though the attention of the patient can be 
arrested by direct address. The death is generally 
easy, when the nerve centers have been the battle- 
ground of the disease. When this is the case, there 
is violent delirium, but the patient is not conscious of 
suffering. 

Most of the deaths were from suppression of urine, 
and the immediate occasion of dissolution appeared to 
be a dropping of the pulse, while the temperature 
remained the same. When death follows close upon the 
black vomit the patient sinks exhausted into a state of 
coma, from whioh he never arouses. The yellow color 
of the skin becomes more and more intense as dissolu- 
tion approaches, and well suggests the propriety of the 
name by which this formidable malady is known. 

The convalescence from Yellow Fever differs from 
that which follows the course of any other disease. 
It is very deceptive. The patient becomes anxious to 
get out, to eat everything within his reach, and men 



54 YELL OW FE VER. 

of intelligence especially, are most difficult to control, 
for they cannot believe themselves to be in danger, 
and yet I have known a relapse to occur from simply 
sitting up in bed and reading the newspaper. Re- 
lapses are very frequent, and occur always from impru- 
dence on the part of the patient, or too great leniency 
on the part of the physician. 

During convalescence the pulse often remains at 
6o° for several weeks, showing the terrible shock to 
the vaso-motor nerves during the course of the fever. 
It is frequently very difficult to bring it up, and any 
extraordinary exertion or imprudence in eating may 
throw the system into a state of collapse from which it 
is most difficult to recover. 

THE DEATH RATE 

of Yellow Fever is for various reasons very difficult 
to determine accurately. During an epidemic such as 
that of 1878, very many cases are not reported. I 
enjoyed an excellent opportunity at Memphis to observe 
this fact, being almost daily in the rooms of the Board 
of Health, and though that body used every exertion 
to obtain accurate reports, the physicians, in most in- 
stances, neglected it, and in others, absolutely refused 
to do so, even when threatened with the penalties of 
the law. As far as I could gather, however, the death 
rate was about 1 to 4 in Memphis. It was greater in 
Grenada and Martin, and less in the other places visited 
by the epidemic. There seemed to be but little differ- 
ence between the higher and lower classes of society, or 
in the various localities of the city, when once the fever 
had taken hold. 



CLINICAL HISTORY. 55 



THE SEQUELS 



of Yellow Fever are very variable. They were for- 
merly not worthy of mention, and when the fever had 
passed off and convalescence set in, the patient was 
popularly considered as really improved by having the 
fever. But this is not so in this mixed manifestation 
of poisons within the system. I should say hybrid 
fever, if I did not reject the idea of any transmutation 
of species, so to speak, in disease ; but certain it is, 
that while the malarial poison has possession of the 
Sympathetic, and the Yellow Fever poison runs riot 
through the Cerebro-Spinal System of nerves, we can- 
not but. expect Sequelae of a most pronounced patho- 
logical character. It is the nervous system which is 
most affected. There is dulness, apathy, indisposition 
to exertion, general malaise — in short, to speak pop- 
ularly, the patient feels absolutely of no account. This 
often lasts for months, and the system does not seem 
to respond to tonic treatment of any sort. The urinary 
organs are often affected. Spasmodic strictures have 
been noted, and a general scantiness of urine, with fre- 
quent straining at micturition. The intestinal canal 
appears least affected, and beyond the mere indisposi- 
tion to eat, the gastric functions do not retain any patho- 
logical marks of the fever. Hemorrhages from the 
nose, gums, and urinary organs frequently occur' for some 
weeks after an attack. 

It is to be noted that these Sequelae are by no means 
constant. They frequently are entirely absent; but 
as far as my observation goes, they are met far oftener 
than formerly, and I firmly believe that this is largely 
due to the malarial complications which aggravate and 



5 6 YELL OW FE VER. 

intensify the symptoms of the pure Yellow Fever, or, 
perhaps, create them, these ravages upon the organ- 
ism being protected from interference by the poison 
of Yellow Fever, which holds the Cerebro-Spinal resist- 
ance at bay. 



TREATMENT AND PROPHYLAXIS. 57 



CHAPTER IV. 

TREATMENT and PROPHYLAXIS. 

THE treatment of Yellow Fever has hitherto been 
entirely empirical. Opposite therapeutic lines 
have been followed with like failure, and with the same 
apparent success. Remedy after, remedy has been sug- 
gested and applied ; but everything proceeding upon 
the specific antagonism of the Yellow Fever poison has 
most signally failed. It is only when the symptoms are 
met, one by one, as they arise, that we have ever been able 
to combat successfully the ravages of the disease upon 
the organism. In Malarial Fever we have a physiological 
antidote in quinine ; but when the Yellow Fever poison 
is diffused through the system, even this will fail to pro- 
duce that antagonizing physiological effect by which the 
malarial symptoms in their purity are usually modified or 
subdued. I have already spoken of the fact that the 
Cerebro-Spinal System is the great field of operation 
for Yellow Fever, and it is well known that the Sympa- 
thetic sustains the same relation to the ordinary Malarial 
Fever. Therefore, when, as we had it in the last epi- 
demic, both poisons exist in the body at the same time, 
quinine cannot reach the malarial poison on account 
of the previous occupation of the Cerebro-Spinal System 
by the poison of Yellow Fever. This introduces us at 
once to a most important therapeutic indication. The 
presence of prominent malarial symptoms would de- 
lusively suggest the use of quinine to combat them; 
but in the experience of most of my professional breth- 
5 



5 8 YELL OW FE VER. 

ren, it was found to be not only not beneficial in its 
effects, but utterly disastrous. Some of us, loth to give 
up the use of a remedy so long the ' sheet-anchor of the 
profession in all manifestations of malaria, persisted in it 
until our increasing death rate and the most apparent and 
positive deleterious effects under its administration forced 
us to abandon it. As a tonic in the convalescent stage 
of the fever it did well ; but as a malarial antidote it 
utterly failed. 

I have thought these observations upon the use of 
quinine in this fever of such prime importance as to serve 
well as an introduction to the therapeutic suggestions 
which follow. 

I do not propose to recount the various lines of treat- 
ment which have been enthusiastically endorsed and 
pursued by the profession in this disease, but simply to 
record what my own experience and observation has 
demonstrated to be most successful in controlling the 
symptoms as they arise in the course of this formidable 
malady. 

When the rigor or chill which ushers in the disease 
comes on the patient should be put to bed at once, and 
blankets supplied. The. feet should be plunged into a 
hot mustard bath underneath the bedclothes. The water 
should be renewed in ten minutes, and not allowed to 
cool. It should be as hot as the patient can bear. 
This bath should last at least fifteen minutes. A mus- 
tard plaster hve inches broad should be applied to the 
whole length of the spine from the occiput to the end 
of the sacrum. The mustard should be covered with 
gauze, not linen or cotton. This should remain at least 
half an hour, and longer if the patient can bear it. 
During all this time he should be enveloped in blankets, 
and the temperature of the room not allowed to go be- 
low 75 Fahr. Three tablespoonsful of castor oil should 



TREATMENT AND PROPHYLAXIS. 59 

now be administered, and the patient kept quiet for six 
hours, with iced lemonade placed beside him, of which 
he may partake ad libitum. If the stomach rejects the 
oil it should be administered by the rectum. Cold 
clothes should be applied to the head, or what is better, 
when they can be obtained, ice bladders. These should 
be kept there, and as the fever rises they should extend 
along the course of the carotids on the neck. After the 
oil operates the following prescription should be admin- 
istered, to guard against renal infarction, and consequent 
suppression early in the action. 

R 

Ammonise Phosphatis, 1 &* 

Sodae Hyposulphiti, J giij 

Aquae Aurantii florum, gvj 

M. 

S. Tablespoonful every four hours. 

This will fulfil two indications ; first, it will prevent by 
the phosphate of ammonia the solution of the albumen 
of the blood, and its consequent exosmosis into the tubes 
of the kidney ; second, it will arrest fermentation in the 
blood by the hyposulphite of soda, 'thus preventing car- 
bonic acid from being set free, and the consequent solu- 
tion of the albumen. It acts also as a diuretic, and 
assists in elimination, which is the great end to be at- 
tained in the treatment of Yellow Fever. 

For the first day the patient should be allowed nothing 
to eat or drink but lemonade. He may use brandy 
freely, but not champagne or fermenting drinks, as they 
are apt to acidify the stomach and set up gastric irrita- 
bility. With these directions, we may generally wait 
twelve hours without further interference. 

The patient should not be allowed to raise his head 
from the pillow. The bed-pan is to be used, and drinks 



60 YELL OW FE VER. 

are to be administered through the funnel cup, with both 
of which named articles the drug stores should be pro- 
vided during an epidemic. This is absolutely essential. 
In no disease is attention to details such as these so 
important as in Yellow Fever. There should be no one 
allowed in the room but the physician and the nurse. 
The light should be subdued, and there should be per- 
fect quiet. The air of the room should be fumigated 
with sulphur and chlorate of potash pastiles, and the 
bedclothing of the patient sprinkled with cologne water. 
Such directions may appear trivial, but the physician 
who attends to these apparently trifling details will be 
amply rewarded in observing the effect upon the patient. 
Any sort of excitement — pleasurable or otherwise. — is 
detrimental. All conversation should be forbidden, and 
the nurses should be charged with this most emphatic- 
ally, both as regards themselves and others. 

If gastric irritability should arise the following pre- 
scription should be resorted to. In fact, it should be 
kept constantly in the room to be used promptly : 

R 
Creosoti, gtt. xx 

Morphiae Sulphatis, gr. j 

Sp. Vini Gallici, gij 

M. 

S. Teaspoonful at intervals not shorter than one 
hour. 

-If restlessness and jactitation should require interfer- 
ence the best hypnotic will be found in the following : 

Potassii Bromidi, gvj 

Chloral. Hydr. f . ' §i 

Aq. dest., giij 

w. 

S. Teaspoonful as indicated* 



TREATMENT AND PROPHYLAXIS. 61 

It will not do to administer morphine or opium in any 
form to the extent of hypnotism, as it produces a hyper- 
aemic condition of the brain, which is a pathological con- 
dition to be avoided. 

If, after the use of the phosphate of ammonia and 
hyposulphite of soda, suppression should occur, efforts 
must be made to drive the urine through the tubes of 
the kidney, and with it the impacted albumen. For 
this purpose watermelon -seed tea seemed to be the 
favorite agent ; but in my hands and under my obser- 
vation, I have found no diuretic to succeed in emptying 
the blood of urine, since the obstruction is a mechanical 
one. In a few instances, I have known diuresis to occur 
after the use of large doses of oil of turpentine poured 
upon sugar, and administered constantly to the patient ; 
but the number of instances in which the suppression 
was relieved by this method was not sufficient to estab- 
lish it as a positive therapeutic agent in this condition. 
Buchu is worthless, and, in fact, all the ordinary diuret- 
ics signally fail to produce any effect. Flannels steeped 
in hot water and placed over the kidneys sometimes 
relax and open the tubes, so that by a powerful diuretic 
stimulant they may be emptied ; but very seldom does 
this occur, and there is but little hope for the patient 
when the urine shows the presence of albumen, and 
suppression has taken place. I look upon this patho- 
logical condition as utterly beyond the reach of thera- 
peutics, and I have never felt so helpless as when brought 
face to face with this peculiar pathological factor in the 
disease. However, we must do something, and the 
only hope is dilatation of the tubes and stimulation of 
the excretory functions. It is for this reason that I so 
earnestly urge the use of the formula, which I have 
given for the prevention of this formidable pathological 
condition. 



62 YELL OW FE VER. 

After the first day the patient may be allowed a little 
beef-tea and the yellow of a hard boiled egg, chopped up 
very fine. During the first of the late epidemic large 
shipments of champagne were made to Memphis, and 
were at once taken up by the physicians and freely and 
indiscriminately used among the patients. So evil was 
the effect produced that some of us publicly implored the 
good people throughout the Union to desist from send- 
ing it. Nothing but brandy or good whiskey will do as 
a stimulant in Yellow Fever. I think in this, the most 
experienced will bear me out. These may be used 
freely — of course not to the point of intoxication. 
The pulse does not appear to be quickened by them, 
and the perspiration is decidedly freer ; so also the excre- 
tion of urine. 

From this time on until the fever breaks, our object 
must be to cool down the system. Use ice freely exter- 
nally and internally. I have kept the head packed in 
ice bladders for days without intermission, and always 
with good effect. 

Sponging with whiskey and water produces often a 
wonderful effect. It will control the fever effectually 
when all else has failed. When it is properly done, it 
is in my opinion the most satisfactory remedial agent 
that can be employed. It should be done under the 
bedclothes, and after the body has been wiped dry the 
patient should be well covered and protected from 
draught. These spongings should be repeated every 
half hour while the fever is raging. If I dared to do so, 
I should recommend the German treatment of keeping 
the patient under water kept a fixed temperature for 
several days. 

I doubt not that it would diminish the mortality of 
Yellow Fever ; but, as in the old fable, though we all 
agree that it is rational and ought to be done, not a 



TREATMENT AND PROPHYLAXIS. 63 

mouse is to be found who will bell the cat. Certain it is 
that the most satisfactory results were obtained by the 
use of water freely. A Russian bath would be the very 
thing, if it were practicable, and I am resolved to have 
one conveniently erected for constant use in the next 
epidemic which shall visit us. Here we have a pyrexia 
— in common parlance inward fire> and outward too, 
for that matter. Water and ice will cool it, and cool it 
effectually. The wet pack is a very rational line of 
treatment. I only saw it applied in one instance, and 
that successfully.. The fact is, we have all been too 
timrd in applying our philosophy of treatment. 

With what breathless anxiety -did we await the result 
of Dr. Choppin's sprinkling treatment with his patient 
in New Orleans, and not a man of us had the courage 
to carry it out, though I have yet the first one to meet 
who does not endorse it as rational. Water is the rem- 
edy in Yellow Fever. 

In regard to the diet of the patient as the fever pro- 
gresses, I know of nothing more grateful or harmless 
than good fresh buttermilk. It should be iced, and the 
patient may take it whenever he chooses. 

After the second day, unless the symptoms impera- 
tively demand interference, all medication should be 
stopped, — lemonade, buttermilk, and a little brandy, 
with frequent sponging, furnishing the best line of 
treatment. There will, however, be likely to arise 
obstinate constipation, which is best relieved by freshly 
prepared Citrate of Magnesia ; and, if that does not 
operate, an enema of castor oil and Castile soap should 
be resorted to. 

Whenever black vomit is threatened the creosote and 
morphia mixture should be promptly used, and in order 
to restore the tone of the stomach, and also to prevent 



64 YELL OW FE VER. 

or check hemorrhage, I have found the folio win o- an ex- 
cellent formula: 

R 

Tinct. Cinchonae, > aa 

" Calumbae, J gi ss 

" Ferri Muriat., gj 

M. 

S. Teaspoonful every four hours. 

This is to be used where the retching is violent, or 
when hemorrhages are threatened ox occur. Along 
with this, pounded ice should be always kept by the bed- 
side, and the patient allowed to partake of it freely. 

If the pulse and the temperature should keep up not- 
withstanding the sponging and cold applications, Tinc- 
ture of Aconite may be used with caution, say begin- 
ning with three drops every half hour, and increasing it 
gradually according to circumstances, in the course of 
twelve hours, or until there is some marked impression 
made. Very great care is needed here, for, as we have 
said, it is much easier for us to bring down a pulse than 
to bring it up, and if the temperature remains the same, 
then everything which depresses the circulatory system 
is contraindicated, and stimulants should be at once re- 
sorted to. 

In regard to Calomel, I am free to say that my ex- 
perience is decidedly adverse to its use, except in 
very minute doses. During the pyrexia, when the 
liver and secretory apparatus generally was threatened 
with engorgement, I have seen - of a grain of Calomel 
administered every hour prove greatly beneficial, putting 
the whole alimentary canal under the stimulus of healthy 
bile, and, in fact, opening up generally the channels of 
the system. 

As an eliminator Iodide of Potassium frequently will 



TREATMENT AND PROPHYLAXIS. 65 

favorably turn the tide of the disease, but great care 
must be observed with regard to the time aiad quantity 
of its administration. It should never be used when the 
stomach is irritable, and in larger doses than five grains, 
which may be repeated every half hour until the effects 
are observed. 

In regard to the various remedies that have been used 
for the first time in this fever during the late epidemic, I 
hcfye nothing to say, except one which was much vaun- 
ted as a diuretic. I speak of Jaborandi. Scarcely a 
paper failed to contain some recommendation of this 
remedy, but I have failed to see the slightest good effect 
from its use ; nor do I believe that its administration to 
this end is at all rational or scientific, for reasons already 
suggested. 

What I have already given covers the medication 
necessary in Yellow Fever. As far as possible the use 
of drugs should be avoided. Nursing — careful, anxious, 
incessant nursing — is the Hamlet of the play in Yellow 
Fever. Water, ice, lemonade, buttermilk and prudence, 
— these furnish the basis of therapeutic action in this 
disease. 

During convalescence the patient should be most care- 
fully watched, as he will most certainly act with impru- 
dence if allowed to do so. The diet should be very 
light — 4ov the most part broth. A dried herring — broiled 
on the coals — may be eaten daily ; in fact, I have known 
this little fish to quiet the stomach when black vomit was 
threatened, and nothing else-seemed of any avail. The 
idea was first suggested to me at sea, where, in most 
instances, I found it an effectual antidote to sea-sickness. 

Quinine may be used in tonic doses with good effect 
during convalescence. I know of no better tonic, how- 
ever, during the convalescent stage of Yellow Fever 
than Caswell, Hazard & Co.'s Ferro Phosphorated Elixir 



66 YELL OW FE VER. 

of Calisaya. It is grateful, assimilable, and invigor- 
ating. 

If the patient is an habitual smoker, he may smoke 
moderately during convalescence, and it often appears 
to have a fine effect upon the nervous system. 

The use of ale or beer, when agreeable to the taste of 
the patient, may be entered upon early in convalescence. 
All oily or greasy substances should be avoided ; so also 
sugars of every sort. 

Particular attention must be paid to the temperature 
of the room. It should be kept equable and entirely 
free from draughts. The mind of the patient should, as 
far as possible, be kept quiet and free from anxiety, care, 
and excitement. 



PROPHYLAXIS. 

There are two standpoints from which to view this 
branch of our subject ; First, as to individuals ; Second, 
as to communities. 

As to the individual it might be expected that my ob- 
servations must be brief. 

It has for many years been supposed that one attack 
of Yellow Fever imparts to the system immunity from 
another. My venerable friend, Prof. Dowell, of Gal- 
veston, still strongly adheres to this belief. But, while 
I am ready to accept this as a fact in the history of the 
disease, as manifested in its former purity, I cannot but 
think that the experiences^ of the last epidemic go to 
show that malarial influences have so modified the mani- 
festation of the Yellow Fever poison, as to diminish in 
a large degree the protection afforded by previous inocu- 
lation. 

Very many persons died of Yellow Fever in 1878, 
who had come through violent attacks in 1873, and, in- 



TREATMENT AND PROPHYLAXIS. 67 

deed, so marked was this fact, that the inhabitants ceased 
to. rely upon the immunity supposed formerly to be en- 
joyed by those who, during previous epidemics, had 
yielded to the poison. 

As to any protective agents, Iknow of none that may 
be used as specific prophylactics, and yet there are steps 
which may be taken, and which I shall enumerate, that 
may serve to strengthen the powers of resistance in the 
organism, or at least very much modify the attack if it 
should occur. 

The bowels should be kept regular, and if there is 
constitutional predisposition to constipation, they should 
be kept a little loose by the use of Seltzer Water, or 
some other mild saline laxative. Lager Beer should be 
used freely every day in quantities sufficient to act freely 
upon the kidneys. The diet should be light and nutri- 
tious, avoiding all heavy meats, pastry and sugars. 
Phosphate of Ammonia, and Hyposulphite of Soda (see 
Formula, page 59) should be taken once a day to pre- 
vent the development of microzymes in the blood. If 
this, however, becomes disagreeable to the stomach, it 
should be discontinued. The skin should be kept active 
all the time. For this purpose small portable vapor 
baths should be procured and used by one exposed to 
the infection every night before retiring, taking care to 
rub the person dry afterwards. Frequent ablutions are 
beneficial. The mind should be kept free from anxiety. 
No person who fears the fever should remain within 
range of its infection, if it is possible for him to get off. 
Likewise all recklessness should be avoided, and a per- 
fect equanimity diligently cultivated. 

Quinine, as an antiloimic agent, is utterly worthless, 
and, I believe, most positively harmful. 

No eruptions upon the skin should be checked. A 
gonorrheal flow should be allowed to take its course. 



6S YELL OW FE VER. 

Venereal indulgence should be limited. It more than- all 
else puts the system in a proper trim for the fever. 
Flannel should be worn next the skin, and changed twice 
a week. Night air should be avoided as much as 
possible. The bed should be rolled in the middle of 
the room, and the whole house should be ventilated 
through the day and closed at night. 

Sulphur should be burned and powder exploded in 
every room at least once a day — better in the afternoon. 

Exercise should be taken daily, but it should be neither 
violent nor protracted. Exposure to the sun should be 
avoided as much as possible. 

Smoking, when in the sickroom, has been proven to 
be to some extent prophylactic. 

A certain amount of sleep is required — six hours at 
the very least — and there must be no extra exertion or 
overwork. This, I regard especially, as an important 
injunction, since those who remain during an epidemic, 
generally, in their efforts to serve others lose all thought 
of themselves, and sink with prostration in the midst of 
the excitement and enthusiasm which surrounds them. 

But the best of all prophylactics is to remove from the 
infected districts. This is not only expedient, but it is 
the bounden duty of every one who is not rendering 
actual service to the sick and needy. 

As to communities, the question of prophylaxis has 
two aspects — i7iter7ial and external protection. 

But little benefit seems to have been derived from the 
use of fires built along the streets. There were large 
quantities of sulphur consumed in Memphis. At night 
the very air was laden with the fumes, yet it did not 
appear to have any effect whatever in checking the rav- 
ages of the pestilence. It was, however, a source of 
comfort,* and of a certain degree of satisfaction to those 
who saw it, to know that efforts of some sort were being 



TREATMENT AND PROPHYLAXIS. 69 

made to stay the hand of the destroyer, and especially 
upon the minds of the lower classes was this effect pro- 
duced. 

In the summer of 1877, at the meeting of the Amer- 
ican Association for the Advancement of Science, a paper 
was presented and read by Mrs. Ingram of Nashville, 
upon the destruction of germs in the air by concussion, 
illustrated by the killing of musquitoes in a room by the 
explosion of a small quantity of gunpowder. During 
the epidemic I received several letters from this lady 
urging the firing of cannon throughout the city. Others 
also favored the trial, but it was utterly as impracticable, 
as it was impossible, in times like those, to obtain gunners, 
and to carry out to any practical extent the application of 
the theory. I have no doubt, however, that it might 
prove of considerable value if it could be practically car- 
ried out. 

The disinfection of localities is a matter of time. It 
cannot be done after the epidemic has set in, and, in fact, 
Yellow Fever does not seem to like one place any better 
than another, and I have often thought that if there was 
any difference the most cleanly portions of the city suf- 
fered most the ravages of the fever ; and yet it cannot 
be denied that proper hygienic surroundings are in gen- 
eral better likely to place the systejn on a higher ground 
of resistance than the opposite condition. 

For the protection of communities visited by Yellow 
Fever, I know of no grander nor more successful scheme 
than that originated and carried out by Gen. Luke E. 
Wright and the late Charles G. Fisher, of the Citi- 
zens Relief Committee at Memphis. 

Several miles outside of the city a large camp was 
org&tized under military discipline. Col. Jno. Cameron 
was placed in charge. His gallant company, the Bluff 
City Greys, and a finely organized colored company un- 



70 YELLO W FEVER. 

der command of Capt. J as. Glass, performed guard duty 
during the whole of the epidemic. Tents were forwarded 
by the Government, and nearly a thousand persons were 
at times accommodated in the camp. A regular Quar- 
termaster and Commissary Department was organized, 
and rations daily furnished. A hospital was erected, and 
all persons coming into camp with the fever in them, or 
on them, were sent thither, and attended by a regularly 
appointed surgeon — Dr. R. B. Nall, of Memphis. No 
person was allowed to enter or leave camp without a 
permit, and everything was furnished from the city by 
a special train leaving daily for the camp and returning. 

In this way the fever was kept from spreading, and 
the camp throughout the whole course of the epidemic 
enjoyed unusual health for that season of the year. 

This system of depopulation proved such a brilliant 
success that I have thought it worthy of special and de- 
tailed notice. It should be adoptee^ promptly at the very 
beginning of the epidemic, and martial law called in 
requisition if necessary to enforce its acceptance by the 
people. It is effectual, practicable, economical, and ex- 
pedient. 

And now as to the external aspect of prophylaxis as 
applied to communities. 

This brings us face to face with the questio vexata of 
Quarantine. In the Chapter on Etiology, I have already 
intimated that the idea of a general quarantine is utterly 
preposterous. In the first place, it proceeds upon a false 
basis of Etiology. I have shown that while Yellow Fever 
may have originally been an imported disease — an exotic 
— it is now no longer so. 'Just a v s some plants, which, 
when originally brought to our latitude required the pro- 
tection of hot-houses and tender nursing, but now grow 
wild in our woods; so has Yellow Fever become 'modi- 
fied by the changed external conditions to which for 



TREATMENT AND PROPHYLAXIS. 71 

years it has been subjected, and adapted to its surround- 
ings by those immutable laws of assimilation and selec- 
tion which govern all life from the protozoa to the verte- 
brates ; and in this modified manifestation it is indigen- 
ous. 

But the advocates of quarantine triumphantly assert 
that some of the smaller towns along the lines of travel, 
where quarantine was rigidly enforced were not visited 
by the epidemic, and this is offered as a conclusive argu- 
ment in its favor. But this proves nothing ; for in the 
neighborhood of those towns were others where the 
quarantine was not enforced, and where not a single 
case of fever occurred, except what was imported. For 
example, the town of McKenzie, fairly interlaced by 
the channels of the epidemic, with free entry and exit, 
two main railroad trunks crossing it, and coming in 
every direction from the infected districts, and yet not a 
single case of indigenous fever. Can the supporters of 
the quarantine say whether the small towns which they 
cite enjoyed their immunity from natural causes or from 
the efficiency of quarantine ? I think not. 

And again, quarantine can never be perfect, and is 
therefore impracticable. It would require a cordon of 
ships from the Bay of Fundy to the Gulf of California, 
so close together as to touch each other, in order effect- 
ually to carry out to perfection the prophylaxis of quar- 
antine. One case is sufficient to infect a continent, and 
if a ship is out at sea with Yellow Fever aboard, my own 
experience is, that she will land somewhere despite all 
precautions and restrictions. It is therefore imprac- 
ticable. 

It is, besides, most lamentably destructive to com- 
merce, and damaging to all the interests of a country; 
besides in itself being a source of unlimited expense. 

I can, therefore, do nothing in any way to encourage 



72 



YELLOW FEVER. 



the establishment of a National Quarantine. The battle- 
ground is not here. We cannot keep from our shores 
that which has already become acclimated and indigenous 
to the interior of our land. We must recognize in this 
fearful malady an internecine foe, dangerous and deadly. 
It belongs to us to meet it within our borders, and I 
doubt not that the day will soon come when, as in those 
countries where Yellow Fever had its birth, it will no 
longer be the terror of our people, nor hang like a pall 
over all our social and commercial interests. 



